2. Availability, cost, and prescription patterns of antihypertensive medications in primary health care in China: a nationwide cross-sectional survey
Meng Su PhD, Qiuli Zhang PhD, Xueke Bai MS, Chaoqun Wu MS, Yetong Li BS, Prof Elias Mossialos PhD, Prof George A Mensah MD, Frederick A Masoudi MD, Jiapeng Lu PhD, Xi Li PhD, Sebastian Salas –Vega MSc, Anwen Zhang PhD, Yuan Lu ScD, Khurram Nasir MD, Prof Harlan M Krumholz MD†, Prof Lixin Jiang MD†

3. Abstract
Background- Around 200 million adults in China have hypertension, but few are treated or achieve adequate control of their blood pressure. Available and affordable medications are important for successfully controlling hypertension, but little is known about current patterns of access to, and use of, antihypertensive medications in Chinese primary health care.
Methods- We used data from a nationwide cross-sectional survey (the China Patient-Centered Evaluative Assessment of Cardiac Events Million Persons Project primary health care survey), which was undertaken between November, 2016 and May, 2017, to assess the availability, cost, and prescription patterns of 62 antihypertensive medications at primary health-care sites across 31 Chinese provinces. We surveyed 203 community health centers, 401 community health stations, 284 township health centres, and 2474 village clinics to assess variation in availability, cost, and prescription by economic region and type of site. We also assessed the use of high-value medications, defined as guideline-recommended and low-cost. We also examined the association of medication cost with availability and prescription patterns.

4. Findings- Our study sample included 3362 primary health-care sites and around 1 million people ( people at 2758 rural sites and people at 604 urban sites). Of the 3362 sites, 8·1% (95% CI 7·2–9·1) stocked no antihypertensive medications and 33·8% (32·2–35·4) stocked all four classes that were routinely used. Village clinics and sites in the western region of China had the lowest availability. Only 32·7% (32·2–33·3) of all sites stocked high-value medications, and few high-value medications were prescribed (11·2% [10·9–11·6] of all prescription records). High-cost medications were more likely to be prescribed than low-cost alternatives.
Interpretation- China has marked deficiencies in the availability, cost, and prescription of antihypertensive medications. High-value medications are not preferentially used. Future efforts to reduce the burden of hypertension, particularly through the work of primary health-care providers, will need to improve access to, and use of, antihypertensive medications, paying particular attention to those with high value.

5. Table 1: Characteristics of primary health-care sites and Million Persons Project population included by rural and urban area
Table 1: Continued

6. Table 2: Availability of individual and classes of medications among all primary health-care sites

7. Table 2. Continued

8. Table 2. Continued

9. Table 2. Continued

10. Figure 1: Availability of antihypertensive medicines in China by type of site and economic region.
Data are percentage (95% CI). The four classes of antihypertensive medicines assessed were angiotensin converting- enzyme inhibitors or angiotensin-receptor blockers, beta-blockers, calcium-channel blockers, and diuretics. Definitions of the three economic regions are in the appendix.

11. Figure 2: Availability and prescription of medications in China by value quadrants

12. Figure 3: Annual costs per patient compared with availability and prescription patterns of antihypertensive medications. Data are (A) percentage point increase (95% CI) and (B) and (C) percentages

13. Conclusion
This study revealed key obstacles to progress in mitigating hypertension in China.
Despite advances in health-care coverage and policy to limit financial risks and improve health outcomes, this study highlighted deficiencies in the availability, cost, and prescription of antihypertensive medications.
Future policies aimed at alleviating the burden of hypertension in China, particularly through the work of primary health-care providers, will need to improve access to high-value antihypertensive medications.